Foundations of an EHR

Identifying current processes, paper and electronic forms, (clinical decision support tools), and workflow processes is the foundation to building an effective EHR. When an organization manages its forms, paper or electronic, it manages its processes. Many forms are necessary for collecting and documenting patient information. Unfortunately, most organizations do not see the value of managing these documents. Whether for electronic or paper, forms management includes the design, creation, revision, and obsolescence of these decision support tools. Maintaining proper version control is essential to meet the current standards of documentation dictated by regulatory agencies and the organization itself. Standardizing forms used throughout the healthcare facility plays a large role in helping the clinical staff to know what data to collect and document which forms are available, and where to access them. This facilitates the delivery of proper patient care. Additionally, standardization saves costs not only in the production of the form, but also in the use of the form. Forms management does have an effect on patient safety and the quality of care. Proper forms management can greatly assist the development of an EHR. Understanding existing forms and processes is necessary for developing accurate electronic processes in the EHR. Before an EHR is implemented a disaster recovery plan must be defined. This plan must identify the paper forms required for use. These paper forms must continue to meet the requirements of creation, revision, version control, and obsolescence to meet the ongoing needs of the current documentation processes. It is necessary to have correct, backup paper data collection tools for clinical and business operations to continue. Often a forms analysis, which documents the current state, is a first step in migrating to an EHR. This is extremely valuable for an organization to know its current used forms, volume, costs, workflow, and production information. This enables the organization to make future decisions based on this information. If a bad process is not identified before automating it, one now has a very expensive bad process. Assessing the current forms management environment can significantly decrease this risk and increase the effectiveness of the EHR and guarantee its successful implementation.

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